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Combined application of CytoSorb and CRRT in a patient with acute renal failure and septic shock as a consequence of lower respiratory tract infection
Dr. Ajay Gupta | Max Super Specialty Hospital, Shalimar Bagh, India
12/04/2019
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Summary
CoW 49/2019 – This case reports on a 57-year-old female patient, who was transferred from a peripheral hospital to the emergency department of Max Super Specialty Hospital, Shalimar Bagh, with complaints of abdominal pain, breathlessness and fever over the previous 2 days.
Case presentation
Known medical history included diabetes mellitus, hypertension and osteoarthritis
On admission, her heart rate was 116/min with a blood pressure of 133/81 mmHg
Due to respiratory distress, the patient was intubated and mechanically ventilated. Oxygen saturation was 91% on the ventilator (FiO2 60 %, PEEP 8 mmHg)
Her APACHE II score was 33
Arterial blood gas analysis revealed severe metabolic acidosis (pH 6.89, lactate 12.7 mmol/l, pCO23 mmHg, pO2 81.3 mmHg, HCO3– 9.6 mmol/l, FiO2 1.0 mmHg)
Chest X-ray exhibited bilateral non homogeneous opacity (RT>>LT) while the ECG showed sinus tachycardia
The patient showed elevated markers of inflammation/infection (leucocyte count 42,500/µl, procalcitonin (PCT)> 100 ng/ml), indicative of an ongoing systemic hyper inflammatory response to an infectious origin
Additionally, laboratory diagnosis showed increased serum creatinine levels (3.38 mg/dl) with minimal urine output
Analysis of endotracheal secretions showed Klebsiella spp. and Candida tropicalis resulting in the working diagnosis of septic shock as a consequence of lower respiratory tract infection
She was started on broad-spectrum antibiotic therapy using meropenem and teicoplanin, and fluid resuscitation was initiated
Antibiotic therapy was supplemented with administration of hydrocortisone in the context of septic shock
After transfer to the medical intensive care unit, she had a further drop in blood pressure followed by initiation of norepinephrine, epinephrine and vasopressin infusions for hemodynamic support
Bedside echocardiography was without pathological findings
Due to persistent lactic acidosis, severe hemodynamic instability with high catecholamine and vasopressin requirements, as well as development of anuric acute renal failure, a right femoral hemodialysis catheter was inserted followed by initiation of combined Continuous Renal Replacement Therapy (CRRT) with CytoSorb therapy
Treatment
One CytoSorb session was performed for 24 hours along with CRRT
The adsorber was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) and run in CVVHD mode
Blood flow: 100 – 150 ml/min
Anticoagulation: heparin (500 IU/hr decreased to 100 IU/hr due to high aPTT )
CytoSorb adsorber position: pre-dialyzer
Measurements
Hemodynamics and requirement for catecholamines and vasopressin
Inflammatory status
Markers of organ dysfunction
Metabolic status
Overall clinical status
Results
Hemodynamic stabilization with a significant improvement in mean arterial pressure and heart rate was noted as a result of the treatment, accompanied by a decrease in norepinephrine, epinephrine and vasopressin requirements. Catecholamine and vasopressin support could be completely weaned off on the 3rd day
During the course of treatment, leucocyte count deceased to 18,000/µl and PCT levels decreased to 4 ng/ml
Furthermore, combined application of CytoSorb and CRRT resulted in a decrease in creatinine levels to 1.8 mg/dl and of bilirubin from 1.8 to 1.1 mg/dl
Metabolic acidosis also improved as indicated by a clear decrease in plasma lactate levels
The patient showed a clear improvement in her general clinical condition during and after combined CRRT and CytoSorb treatment
Patient Follow-Up
Following the 1st CytoSorb treatment, the patient could be gradually weaned off the ventilator and was extubated 4 days after admission
After cessation of CytoSorb therapy she was put on sustained low efficiency dialysis (SLED) which, after stabilization and extubation, was switched to hemodialysis for treatment of her renal failure
She was discharged after a total of 7 days to the peripheral hospital for further dialysis care
Conclusions
In this patient diagnosed with acute renal failure and septic shock as a consequence of lower respiratory tract infection, the combined use of standard of care and CytoSorb with CRRT proved to be very efficient in stabilizing the hemodynamic, inflammatory and metabolic situation and led to a clear improvement in the patients’ general clinical condition
This case highlights the importance of using CytoSorb at the right time, where the correct use of CytoSorb therapy helped regain control in the acute phase of the patient’s condition and lead to survival of the patient
Application of CytoSorb was safe and without any side effects
